- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,786.30 / $11,481.54
| Facility | | $1,548.82 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $3,235.94
| Professional | | $1,174.90 | $1,445.44 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $8,317.64 / $15,488.17
| Facility | | $3,090.30 | $8,317.64 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $3,235.94
| Professional | | $1,023.29 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,454.71 / $10,000.00
| Facility | | $1,445.44 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $4,265.80
| Professional | | $1,258.93 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $12,302.69
| Facility | | $1,949.84 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,951.21
| Professional | | $1,096.48 | $1,548.82 | $2,951.21 |